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About this book

A broad-ranging introduction to the provision, funding and governance of health care across a variety of systems. This revised fifth edition incorporates additional material on low/middle income countries, as well as broadened coverage relating to healthcare outside of hospitals and the ever-increasing diversity of the healthcare workforce today.

Table of Contents

Chapter 1. Comparative Health Policy: An Introduction

Abstract
Health care has always been a controversial policy area, but lately it has become a major issue in all developed nations. Ageing populations, the proliferation of new medical technologies and heightened public expectations and demands, among other factors, have elevated health care to the top of the political agenda. Intensifying pressures on political leaders to meet rising public demands for expanded service conflict directly with the need to constrain health care costs and to manage scarce societal resources. Thus, despite major differences among countries as to how health care is funded, provided and governed, no government can escape the controversy and problems accompanying health care in the 21st century, although some seem to be coping significantly better than others. Health care has always been a controversial policy area, but lately it has become a major issue in all developed nations. Ageing populations, the proliferation of new medical technologies and heightened public expectations and demands, among other factors, have elevated health care to the top of the political agenda. Intensifying pressures on political leaders to meet rising public demands for expanded service conflict directly with the need to constrain health care costs and to manage scarce societal resources. Thus, despite major differences among countries as to how health care is funded, provided and governed, no government can escape the controversy and problems accompanying health care in the 21st century, although some seem to be coping significantly better than others.
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 2. The Context of Health Care

Abstract
The health policy of any country at any point in time is the product of a multitude of factors, the most important of which are displayed in Figure 2.1. These factors include the intrinsic social, cultural and political fabric of a country, including its social values and structures, political institutions and traditions, the legal system and the characteristics of its health care community. For instance, policy-making authority might be highly centralized or widely dispersed across multiple levels. Moreover, in some countries unions and/or corporate structures are strong factors in determining social policy and might, in effect, have a veto power over proposed policy changes made by the government. Likewise, the influence of the medical industry and medical and nursing associations varies widely, as does the power of insurance providers in shaping health policy. The practice of health professions can also be strongly affected by the legal system and its role in compensation claims and the definition of legal rights to health care services. Moreover, in some countries the courts can challenge and even negate government policies, while in others the government is supreme and its decisions are the law. Social values, too, are important forces, with some traditions emphasizing individual rights and entitlements and others putting heavy emphasis on collective or community good. The boundaries as to what is a ‘public’ good and what should remain in the private sphere also impact on health policy. Countries with stronger socialist roots are likely to define public goods and services much more broadly and to include universal coverage. Furthermore, in some societies like Japan and Taiwan, the extended family still plays an important role in health care while in others even the nuclear family has diminished importance in its delivery.
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 3. Funding, Provision and Governance

Abstract
Health care is often thought of as a system, which consists of a range of sub-systems. Among these, the sub-systems of funding, provision and governance are central for understanding health policy comparatively. The sub-system of funding is concerned with raising financial resources and allocating monies to the providers of health care. Health care can be funded from a range of sources, from taxes and social insurance contributions to private insurance premiums and out-of-pocket payments by patients. Funding, however, is about more than the technicalities of raising and allocating financial resources. Funding is also a pointer to power, and control of funding is a major resource in health policy. The sub-system of provision focuses on the delivery of health services. Health systems provide a range of services, and patients have varying levels of choice when using health services, for instance among individual doctors or different care settings. The delivery of health services is based on the health workforce comprising different professional groups (discussed in Chapter 5), in the hands of different types of providers including public and private, profit or non-profit, and hospitals, ambulatory or primary health care (PHC) and long-term care (LTC) providers (discussed in Chapter 6). The mix of providers makes the provision of health care more or less publicly integrated.
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 4. Setting Priorities and Allocating Resources

Abstract
Chapter 3 demonstrated that health systems display variation in the sub-systems of funding, provision and governance that impact on health policy and health care. It also revealed that these sub-systems are dynamic and that many of them have undergone significant changes in recent decades. To understand their impact on health care, it is important to go beneath the institutional and structural dimensions and examine the goals, objectives and priorities of each health system. This chapter also examines the criteria that health systems use to allocate medical resources and the ramifications of these policies for their respective populations. A successful policy is founded on goals and objectives that should be clarified early in the policy-making process. Two levels of goals are discernible. The first is broad stated goals that often function symbolically and are more in the realm of political rhetoric than reality. The second is specific programmatic goals that frame a specific policy. Both are critical in evaluating the success or failure of a policy. Although some goals can be specified and appraised with accuracy, others are more amorphous; generally, the broader the goal, the more difficult it is to measure. Analysis becomes even more problematic when the goals themselves conflict, are defined differently by the various participants, or they shift over time. Despite these problems, it is critical to examine the stated goals of health policy.
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 5. The Health Workforce

Abstract
Health policy has long reduced health workforce issues to the medical profession while neglecting the vast number of health care workers, and comparative health policy mirrors this problem. Efforts to be more inclusive have gained momentum since forecasts revealed a widening gap between demand and supply, and international organizations took action (European Commission, 2008; OECD, 2008a; WHO, 2008a; Vujicic et al., 2012; Dussault, 2015), reminding us that there is ‘no health without a workforce’ (Campbell et al., 2013). The lack of attention to the human resources of health systems turned from a workforce issue into a system and policy failure. Health workers build the backbone of every health care system. Shortages, maldistribution and mismanagement therefore challenge equity and quality of care in the established welfare systems of the global North, and threaten the implementation of universal health care coverage and the global Social Development Goals (SDGs) in low- and middle-income (LMIC) countries (Bowser et al., 2014; Glinos et al., 2015). Meanwhile, data source and monitoring systems have significantly improved and planning instruments are more complex in almost all OECD countries (OECD, 2013, 2016b; Batenburg, 2015; Joint Action, 2015; WHO, 2015b). Unfortunately, a lack of information on even basic health workforce indicators persists in many middle-income and especially in low-income countries and this limits systematic comparison (Ranson et al., 2010; WHO, 2012a, d; Cailhol et al., 2013).
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 6. Health Care Beyond the Hospital

Abstract
Health systems for many years have been concerned primarily with the provision of medical care and focus on acute illness, and this in turn has promoted a focus on doctors and hospitals as well as on curing as opposed to primary health care (PHC) and long-term care (LTC). Transformations in societies, including demographic changes and ‘ageing societies’, and the changing spectra of illnesses have created a new demand for health care services beyond traditional hospital treatment. A needs-based health service provision, therefore, calls for substantive changes in the organization and delivery of care services (WHO, 2016b). Next to the expansion of health promotion and illness prevention (discussed in more detail in Chapter 7), the major policy goals include strengthening of PHC and the development of a new LTC sector. Less acute care, often including chronic illness and multi-morbidity, is typically characterized by considerable diversity in terms of the range of services, the user groups, the localities of service provision and the professionals involved. There are also important differences between high-income countries and middle-to-low-income countries, especially in relation to LTC. While LTC is a major policy issue in high-income countries, it is not a theme in low-income settings and there is still little activity in middle-income countries although pressures will increase in near future (Rhee et al., 2015).
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 7. Public Health

Abstract
Until now the focus of this book has been on health care policy. We have been concerned with hospitals, doctors and other health care professionals and the funding, delivery and governance of health care services. Largely, the book has centred on the care of individual patients. Chapter 5 demonstrated the wide range of settings and activities in the delivery of modern medical care. Chapter 6 extended this to integrate health care with non-health arenas by demonstrating that it is not possible to disengage health care from social care. The health of a LTC client is as dependent on personal care as it is on medical care, perhaps in many cases more so. Even this more inclusive picture of health care, however, might be criticized for underestimating what are its most important dimensions for some observers: health promotion and disease prevention, which together are often termed public health. Due to the breadth and rather amorphous nature of public health, this chapter is more of an overview of the policy concerns facing our countries than the comparative analysis within previous chapters. Mackenbach and McKee found in a recent comparative analysis of 30 European countries that public health policy does not appear to be strongly influenced by institutional features, while the ‘predominant political influence has been the rise of levels of democracy in countries in the Central and Eastern parts of the region’ (2015: 1298). Examples from our countries, nevertheless, are used throughout the discussion to demonstrate the wide scope of public health issues facing all countries.
Robert Blank, Viola Burau, Ellen Kuhlmann

Chapter 8. Understanding Health Policy Comparatively

Abstract
In analysing health policy in a comparative context, the preceding chapters have covered a wide range of topics including the historical and cultural trajectories of health policy; systems of funding, providing and governing health care; policies of allocating health resources; issues in the health care workforce; primary care and long-term care; and the wide-ranging areas that constitute public health. As in any cross-country comparison, a tension emerges between similarities and difference, between common policy trends, such as the ubiquity of rationing, and policy divergence, such as welfare mix in the provision of hospital services. In their study of 11 high-income countries, Tenbensel et al. similarly found significant ‘islands of difference’ in an overall ‘sea of similarity’ among the health policy agendas of the selected countries (2012: 29). This brings us back to the question of what contribution analysis of a range of countries can make to our understanding of health policy. Comparison is about juxtaposing health systems and health policies across different countries. This allows us to get a better idea about the scope of variation that exists and helps to avoid both false particularism (‘everywhere is special’) and false universalism (‘everywhere is the same’) (Saltman, 2012). Importantly, exploration often leads to deeper questions about why it is we find differences and similarities. As such, comparison offers an important groundwork for explanation.
Robert Blank, Viola Burau, Ellen Kuhlmann
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